By choice or compulsion, Indians across age groups and income categories are falling short in meeting the World Health Organisation (WHO) recommended daily intake of five servings of fruit and vegetable, a new report has revealed.

In consuming only 3.5 servings of fruit and vegetables per day–a third short of the recommended intake–Indians are predisposing themselves to chronic diseases, the reason why the WHO issued that guideline, said the India’s Phytonutrient Report, a new publication by the Indian Council for Research on International Economic Relations and the Academic Foundation.

An affinity for fast food, long work hours and rising prices of fruit and vegetable are the leading reasons for a drop in their consumption.

India now has the greatest disease burden of any country, hastening what experts call an “epidemiological transition” from communicable to non-communicable or so-called lifestyle disease, as IndiaSpendreported, accentuated by a failing public-healthcare system. Healthcare expenses push an additional 39 million people back into poverty every year, this Lancet paper said.

Dietary changes–and chronic disease–accompany economic prosperity

Investigating the causes for the increasing prevalence of chronic diseases globally in the 1980s, the WHO zeroed in on dietary changes. Populations in developed nations and the affluent in developing nations were eating less fruit, vegetables and whole grains, and more of fat, processed food and sugar than earlier generations.

That trend was repeated in India. Affluent Indians were getting 30% of their daily energy intake from fat and were consuming half the amount of dietary fibre than previous generations, concluded this 1991 WHO study.

Trisha Roy, 35, a Pune professional, is aware that the World Health Organisation recommends five servings of fruit and vegetables a day, but she eats 3.5, the average consumed across India. Rising prices–which doubled, in some cases, tripled, over the last decade–prevent her from buying more fruit and vegetable. She tries to buy a variety though, “as that is good for health,” she says.

To stop the spread of chronic diseases, the WHO had recommended eating at least 400 gm—five servings of 80 gm each—of fruit and vegetables a day. Indians have largely ignored that warning and this poor choice is showing up in mortality data.

In the last quarter century, chronic diseases have emerged as the number one cause of death in India:

Heart disease has become India’s top killer, IndiaSpend has reported, striking across income classes in concert with dietary and exercise lapses.

India is seeing a diabetes epidemic, with about one in 10 adults suffering from the disease and more than a million succumbing to it annually.

Cancer has become India’s fourth major killer, doubling its presence since 2004, IndiaSpend has reported.

High cost keeps Indians from consuming enough fruit and vegetables

“We eat potatoes and dal mostly, and green vegetables when they are cheap. I buy bananas for my children about once a week.” — Sujata, 27, a domestic help in Pune.

Sujata is unaware of the WHO recommendation, part of the nine of 10 Indians similarly ignorant.

Helpings of starch-laden potatoes and other tubers don’t count as vegetable servings (see box), and the WHO recommends eating a variety of fruit and vegetables.

“Fruit and vegetables have become more expensive since the rains failed last year, and cost much more in the city than back in our village,” said Sujata, explaining her situation.

The prices of fruit and vegetable rose steadily over the last decade, with most prices doubling, even trebling in the case of sweet potato and ginger.

Wholesale Price Index (WPI) has been used to note the trend of rising prices over the years. A 100% increase means doubling of prices, while a 200% increase means trebling.

Rising food prices affect low-income families the most but the middle class is not exempt.

“I buy fewer fruit, even though I continue to buy a variety, as that is good for health,” said Trisha Roy, 35, a professional in Pune and Sujata’s employer, who is conscious of WHO guidelines.

Cost was the third most frequently cited reason for the low consumption of fruit and vegetables, in the Phytonutrient Report. Correspondingly, higher earners in the five cities tapped for the study—Chennai, Kolkata, Hyderabad, NCR and Mumbai—were found to consume more fruit and vegetables.

“More Chennai and Hyderabad respondents were vegetarian and from higher income families, which is possibly why we found a higher intake of fruits and vegetables in those cities,” said Arpita Mukherjee, professor, Indian Council for Research on International Economic Relations, and the study’s lead author.

“I work long hours during which I only have access to food available in the canteen and in nearby shops. These outlets don’t sell fruit. So I only get to eat fruit when I bring it from home. Frankly, I am neither that organised nor that health conscious,” — Ankita Vaid, 25, public relations executive in Delhi.

Young adults aged 18 to 25 and students eat roughly three servings of fruit and vegetables compared to 3.5 helpings that adults consume, according to the Phytonutrient Report. A busy work life coupled with long working hours was the leading reason cited for low consumption followed by the seasonal (and hence limited) availability of fruit and vegetables.

Ignorance and a sedentary lifestyle has spoilt the diet of Indians, said nutritionists.

“I see so-called health-conscious young adults who eat readymade cereals for breakfast and many skip breakfast, they are in so much of a hurry,” said Shweta Bumb, a Pune-based nutritionist. “At lunch, they eat a serving of veggies. Then they mess things up by eating junk food for dinner and/or on weekends. Nine in 10 of my patients eat one fruit a day, and that too not every day, or not a full fruit.”

More middle-class Indians are eating fast food instead of sabzi-roti-dal-chawal, in the process, limiting their intake of fruit and vegetables. In smaller cities and towns, middle-class households doubled spending on food between 2012 and 2014, the 2014 Assocham paperIndian fast food market new destination: Tier-II & III cities tells us. In metropolitan cities, middle-class households increased spending on fast food by 35% over the same period.

Poor food choices eventually lead to chronic disease.

“Taste drives food choices nowadays,” said Parul Khurana, nutritionist with SCI International Hospital, Delhi. “I see middle-aged, overweight women with high blood pressure and high cholesterol and triglycerides, early signs of heart disease and diabetes, as a result of eating wrong foods like parathas, flattened rice cooked with potato, salty snacks and fast food.”

Five-a-day doesn’t keep the doctor away; Seven to ten, better

Five-a-day is a catchphrase coined to popularise the WHO recommendation to eat five servings of 80 grams a day, 400 grams of fruit and vegetables in all.

India, like Germany, Holland and New Zealand, endorses the WHO five-a-day recommendation. Other countries recommend more helpings of fruit and vegetables, which studies now show can do more to prevent chronic diseases.

Five portions a day are good for children, according to Canadian guidelines. But teens and adults need seven or more servings of fruit and vegetables.

Five servings of vegetables and two of fruit is the Australian guideline, based on the belief that vegetables do more than fruit to keep the body healthy. Last year, a British study validated this belief.

Ankita Vaid, 25, a Delhi-based public-relations executive, eats two servings of fruit and vegetable during her 10-hour work day. She is representative of India’s young adults, whose love of fast food and long work hours leads them to consume three servings of fruit and veggies a day, 40% less than the World Health Organisation recommends. In time, this lifestyle exposes them to a variety of disease.

Vegetables are four times healthier than fruit, said this University College London study, published in the Journal of Epidemiology & Community Health, the first time scientists quantified the health benefit of fruit and vegetables. Every serving of vegetables lowers the risk of dying by 16% while a helping of fruit lowers your death risk by 4%, they estimated.

People who ate seven or more servings of fruit and vegetables a day had a 42% lower risk of death than those who ate less than one portion, the London study concluded. Consuming seven or more servings of fruit and vegetables lowered the risks of dying of cancer and heart disease by 25% and 31% respectively.

Low fruit and vegetable intake is among the top 10 risk factors contributing to explainable mortality, a World Health Report said in 2003. What it means is this: If Indians eat more fruit and vegetable, they will be at lesser risk of death.

WHO Fruit & Vegetable Intake Guidelines

Adults and children must eat five servings of fruit and vegetables daily.

One adult portion of fruit or vegetables is 80 grams. As a rough guide, one child portion is the amount they can fit in the palm of the hand.

To get the most benefit the five portions should include a variety of fruit and vegetables.

Potatoes and other tubers cannot count towards the five-a-day because they contribute mainly starch.

Beans and pulses can supply a maximum of one portion a day, irrespective of how much you eat. Three heaped tablespoons of chickpeas (chana) or kidney beans (rajma) make a portion.

Dried fruit like figs and prunes can contribute to the five-a-day. A portion of dried fruit is 30 grams.

Fruit/vegetable juices and smoothies are best limited to a combined total of 150ml a day.